INTENSIVE CARE SERVICE

NURSING POLICY & PROCEDURES

NAME OF POLICY: INTERCOSTAL CATHETER

GOAL: TO ENSURE DRAINAGE OF PLEURAL SPACE AND/OR

REINFLATION OF AFFECTED LUNGS

Introduction:
There are two pleural membranes. The outer, or parietal, is adherent to the inside of the thoracic
cavity. The inner, or visceral pleura, is adherent to the surface of the lung. There is a small
negative pressure (-4-10 mmHg) between the two, which sucks the visceral pleura onto the
parietal pleura. Therefore in everyday life, the pleural space is only a potential space. A serous
fluid acts as a lubricant between the two membranes. As the visceral pleura is adherent to the
lung surface, the lung is held on to the thoracic wall by virtue of this attachment.

When a person’s ribs move up and out and the diaphragm moves down during inspiration, the
lungs expand to occupy all the available space. This lowers the pressure in the lungs, which
causes atmospheric air to be drawn in. Any injury or pathology that interferes with the integrity
of the pleural membranes can lead to the lung collapsing

There are two main indications for the insertion of an intercostal catheter. The first is to allow
the lung to re-inflate and the second is to facilitate the removal of material from the pleural space
such as fluid, blood, pus or air.

The most common sites for the intercostal catheters are: anterior tube is place in the second
intercostal space in the midclavicular line and an axially tube is place in an intercostal space
from the fifth to eighth intercostal spaces between the anterior and posterior axillary lines.

The anterior tube position is chosen because air floats upwards in the chest
cavity. The posterior tube is placed in a dependent position for drainage, a
site is chosen so that the patient in the supine position will not compress the
tube or be uncomfortable. Any lower than the eighth may compete with the
bulge of the diaphragm into the thoracic cavity. For air and fluid evacuation
a 24 French gauge tube will be usually inserted and 36 French gauge tube
for the purpose of drainage of blood or pus

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Pneumothorax can be related to a surgery procedure (lobectomy, open-heart surgery) or from
trauma (penetrating knife wound, blunt trauma from a fall, or from (baro-trauma) positive
pressure ventilation). Blister and blebs on the lung parenchyma usually cause spontaneous
pneumothorax. All these allow air to enter the pleural space. Air entering the pleural space brings
about an increase in the intrapleural pressure from negative to positive pressure and terminates
the suctioning or pulling effects of the pleural cavity on the elastic lung tissue. The lung
immediately collapses to an unstretched condition, which is about one-third of its expanded size.

Haemothorax is a collection of blood in the pleural space. Haemopneumothorax is both air and
blood in the pleural apace. Like pneumothorax, these conditions result in high intra-
pleural pressures and partially collapse the lung.

Haemothorax

Tension pneumothorax is a more serious complication that can develop when air continues to
leak from hole in the lung into the pleural space and has no way to escape. As more and more air
accumulates in the pleural space, pressure within this space rises significantly. If the pressure
builds up enough, it causes “medialstinal shift” which mean that the entire mediastinal area
including the heart and other structures pushed towards the unaffected or good side. This reduces
the size of the unaffected lung. This is a critical life-threatening situation and requires
immediate attention. Early signs of mediastinal shift may include an overextended chest,
shallow gasping respiration, shift of the trachea in the suprasternal notch and changes in arterial
pulse.

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Pleural effusion is an excess of fluid in the pleural space. Normally the pleural space contains
10mls of fluid. However the volume can increase to more than 1500mls with an effusion.
Effusions typically occur at the base of the pleural space (due to gravity) and can be unilateral or
bilateral. It develops after an underlying condition disrupts the mechanisms that normally control
the movement of fluids into and out of the pleural space. These mechanisms include:

Hydrostatic pressure, which tends to push fluids out of compartment

Colloid osmotic pressure, which tends to pull fluid into compartments
Intact structures such as, capillaries, lymphatic vessels and pleurae

There are two types of pleural effusions

They both cause the same signs and symptoms and require similar treatment. However each
points to different underlying problems

Exudative effusion is generally associated with pleural disease, develops when capillaries
become more permeable and leak protein-rich fluids into the pleural space. Because of its
high protein content, this type of effusion usually resembles plasma. Inflammation of
tissue, lungs, and lymphatic vessels can bring this on; fungal, viral or bacterial lung
infections, subphrenic abscess and cancer.

Transudative effusion occurs when protein-free fluids leak from intact capillaries and
pass through the pores of membranes. This type of effusion is generally associated with
normal lung tissue. It can be found in conditions such as: congestive heart failure,
pulmonary oedema, renal disease and hepatic disease. This type of effusion is also known
as hydrothorax.

Chylothorax is lymphatic leakage into the pleural space with subsequent accumulation. It
usually is milky-white in colour related to its high fat and fat-soluble vitamin content as well as it
being high in protein. The fluid can accumulate at a rate of 1500mls a day causing
haemodynamic compromise and metabolic sequelae due to this loss. The primary causes of a
chylothorax are malignancy, congenital, subclavian vein obstruction, trauma including surgical;
related to mobilization of aortic arch (eg. repair of aortic coarctation, patent ductus arteriosus or
vascular rings) or esophageal resection. The treatment consists of not only the drainage of this
fluid but also aggressive maintenance of fluid and nutritional status.

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 Assisting with the Insertion of a Pleural Drain

Equipment:
Sterile pack, gown and gloves
24 or 36 size tube will be required
Dressing pack
Petroleum impregnated gauze (gelonet)
Aseptic antibacterial solution
One Key-hole gauze
Intercostal set (sterile)
Suture and blade
Single plastic bottle or Thoraseal 111
50mls catheter syringe for usage in one bottle system
Sterile water (500mls)
Kocker clamps, two for each tube. Ensure teeth of the clamp are covered with plastic to
provide safety during clamping
ICC adapters (small, medium large)
Low suction port connected to outlet source (working order) if required
Appropriate “Y” connectors (if multiple ICC are required)
Rack or stand for 1 bottle system
Sterile scissors or large stitch cutter if required
Adhesive for dressing (white large width)
Adhesive for occlusion over each connection site (brown)

UWSD Set-Up Using 1 Bottle System:

Inform patient and significant others where possible
Ensure patient has adequate analgesia (review with RMO)
Reassure patient throughout procedure if conscious
Sit bottle into holding basket
Remove plastic cover from the “vent” side of the one bottle system
Insert 50ml sterile syringe catheter into “vent” side
Using sterile water fill to “0” marker inscribed on the bottle. Do not replace plastic cover
over this “vent”
Ensure sterile drainage tubing is place on Dr.’s. sterile field
Dr. will connect one end of the tubing to the intercostal catheter when ready, the other end
will be connected to the UWSD marked “patient”
Ascertain the size of the ICC tube to that of the drainage tube, it usually is too big. anticipate
using one of the selected connectors (S/M/L)

If suction required follow steps below

Connect suction tubing to suction outlet source and place to the “vent” side of the
bottle
When ready for use turn on the suction at the required kPa as ordered (usually 3-5 )

If no suction is required ensure the “vent” side of the bottle is open to air

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 Ensure clamp is immediately released from ICC after connection
Observe and monitor the system to ensure it’s working correctly (see nursing
responsibilities and trouble shooting below)
Once the purse string has been inserted clean and dress the ICC site
Secure tube to decrease traction
Secure all connection site with adhesive tape
Assess patient respiratory status, during and post insertion
X-ray to clarify tube position and evaluate lung expansion

UWSD Set-Up Using Thoraseal 111 System:

Use the picture below to assist with the set-up

See below for further instructions for Thoraseal setup

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Fill suction outlet to desired level per RMO orders (usually 15-25cm H20)
Fill water seal to inscribed “marked”
level

Connect suction to suction port

After connection to patient, turn on the suction so that gentle bubbling is noted in the
suction chamber. (Vigorous bubbling will cause noise and evaporate the water)
Use Thoraseal built-in hanging device for security

Nursing Responsibilities
At the start of each shift ensure patency the system (see trouble shooting for guidance)
Respiratory assessment
Palpate skin around tube insertion site for subcutaneous emphysema (notify Dr. if present,
see under air leak)
If patient is on suction, turn off the suction for evaluation, at the same time check the
amount of kPa or cm H20 is correct with Dr. orders. If water has evaporated from the
required amount, restore it.
Observe for oscillation/swing/tidelling in the tubing (reversed on PPV)
Observe of air leak (bubbling, continuous or intermittent) If concerned about “air leak” see
under trouble shooting
Amount of drainage, this is usually recorded every 6/24hr on the flow chart and marked on
the bottle accordingly
Ensure there are no kinks in the tubing
Ensure all connections site are secure and have insulate adhesive around each site
Ensure the tubing is secure and that insertion dressing is intact
Record and document finding of each UWSD hourly, report abnormal finding if trouble
shooting has not found and or solved the problem.
Dressings are changed every 48hr or when necessary
Ensure bottle is change if greater than 200mls of fluid is insitu (if using one bottle system
and it is not on suction)
Daily X-ray to assess progress of the condition and to detect complications

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Requiring Fluid Specimens:
The Thoraseal tubing is made of self-sealing silicone, permitting a small needle to be inserted to
withdraw fluid. Follow steps below:

Thoraseal
Ensure universal precaution are undertaken
Anticipate specimen collection when there is drainage in the tubing
Use a 25 gauge needle attached to 5-10mls syringe
Insert needle into tubing with care and extract fluid required
Syringe into yellow top jar and send to appropriate laboratory with forms
Document when specimen was taken

One-bottle system
Do not remove fluid from the drainage bottle as this has been laying insitu for a period of
time and may be contaminated
Ensure universal precautions and apply aseptic technique
Anticipate specimen collection when there is drainage in the tubing
Assess patient respiratory status prior, during and after this procedure
Turn off suction if applicable
Remove adhesive from connector site (closest to the patient) apply antibacterial solution
with gauze
Clamp closest to the patient chest cavity
Disconnect tubing and allow fluid to drain into the yellow top jar
Re-connect tubing and unclamp
Apply adhesive tape to connection site
Re-evaluate drainage system

Trouble shooting

Fluctuation (tidaling/oscillation/swinging)
Tidaling is indicated by fluctuations in the water seal chamber that correlates with the respiratory
cycle. This action reflects the changes in the pleural pressures that occur with respiration.
Fluctuations will be the reverse when PPV in applied.
A rise in the tubing will indicate inspiration and a fall will indicate expiration.

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As suction diminishes tidaling One must evaluate with the suction off. Tidaling will not be
noted if there is an obstruction or if the lung has fully expanded or if suction is on.

Solution:
Observe X-ray for re-expansion of lung, this will be the definitive answer. Even after the
chest tube has ceased to function and the lung has re-inflated sometime the ICC may be
left in for another 24-48hr depending on the patient’s overall physical condition and the
degree of potential recurrence
Auscultate lung field
To clear obstruction check for
Kinks (increases pressure)
Dependent loops (lie tubing flat along the length of the bed)
Clot formation (cough, take a deep breath, change patient position)

Bubbling:
Turn the suction off to evaluate the system and the patient. Diminished bubbling should be a
sign that the lung is re-expanding. Absence of bubbling indicates that evacuation is complete and
the pressure of the expanded lung has sealed the chest tube opening or that the tube is blocked. If
there is a patient air leak, bubbling will be noted on spontaneous expiration, if it is noted that
bubbling is continuous both inspiration and expiration one should suspect an airleak. If PPV is
applied continuous bubbling is present, but if vigorous bubbling occurs suspect an airleak in the
system

Solution:
Check X-ray to confirm lung expansion
Check all connection sites are secure and have appropriate adhesive tape around them
If leak persists follow these steps
Clamp starting at the chest wall and work at intervals moving down the tubing. (For
example you have clamped near the chest wall than bubbling has ceased, the leak
must be in the patient and not in the system, due to dislodged tube or from around the
insertion site. Inform Dr if tube is or has migrated out (one can often see the eyelets).
It may need replacing, no not push it back in. Apply Vaseline gauze (gelonet)
Consider bronchopleural fistula

Milking and Striping:

Striping is controversial and should not be done with out the Intensivist order. Stripping is
known to create transient high levels of negative pressure (-400cmH20) within the pleural space
and cause barotrauma. Milking a chest tube is less stressful on the pleura. It is performed by
gently squeezing the chest tube between your fingers and performing this process down the
length of the tube. Clots and fibrin can obstruct the drainage system, which may require milking.
Ensure Dr. has given the permission

Metal stripping device

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Clamping:
Clamping the tube is only used in the event of tube disconnection or breakage of the bottle. In
such cases the pleural tube can be quickly clamped off, preventing renewed pneumothorax and
consequent collapse of the lung. The clamp should not be left on for long periods as a tension
pneumothorax can develop, putting pressure on the heart, which in turn can lead to cardiac
arrest. The patient should never be left unattended when the clamps are on.

When transporting a patient there is no need to clamp the tubes as long as the system remains
below the patient’s chest cavity and is secure so that no fluid is sucked or poured into the pleural
cavity. If this can not be achieve then clamp the tubes for the shortest possible time.

Intercostal Catheter Falls Out:

Ask Patient to cough (if applicable)
Cover site with petroleum gauze and dry dressing
Stay with patient and assess respiratory/haemodynamic
Notify RMO
X-ray required
Anticipate re-insertion

When to Change the Tubing and Drainage System

One-Bottle System:
If no suction is applied, change drainage bottle if 200ml plus is present. As the drainage
increases the patient effort to expel the air on expiration is made more difficult due to the
increasing pressure the patient has to overcome as the fluid submerges the straw. When
suction is applied this negates the effort on the patient’s part to expel the air so the bottle
does not require changing as often.

Tubing is changed every 48hr along with the dressing. It is usually undertaken at midnight as this
coincides with the overall fluid balance of the patient. (See below for Thoraseal 111 change)

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Procedure:
Universal precautions and aseptic technique
Chose an appropriate time (eg. not after pulmonary toileting)
Monitor respiratory status during and post procedure
Inform patient of procedure
Prepare equipment (as above)
Remove adhesive tape form all connection sites
Ensure new drainage bottle is secure in rack
Swab connection site, closest to the patient
Clamp as close to the patient as possible (as above)
Disconnect old tubing and reinsert new tubing
Unclamp
Apply adhesive tape to all connection sites
Document change and drainage
Assess drainage system

Thoraseal:
The Thoraseal system should be changed every 7 days or if an air-leak is detected in the system.
The same principles and steps are as for the one-bottle system (see above). The need to change
the drainage bottle only may apply. Follow steps below:

Ensure universal precautions

When full, remove adhesive tape around connectors
Clamp closest to the patient and disconnect the tubing
Twist drainage bottle as shown in picture below and replace it with a new one
Connect to patient and unclamp
Ensure adhesive tape around connection site
Dispose of drainage container appropriately
Document change and drainage
Dispose of equipment appropriately

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Removal of an ICC: (Two RNs required)
Inform patient and significant others if applicable
Ensure X-ray confirms re-expansion
Assess for fluctuations in the tubing, there should be none
Sit patient in high fowler position if possible
Consider analgesia if applicable
Remove dressing
Demonstrate action of the Valsalva manoeuvre (increasing the intra-thoracic pressure by
holding ones’ breath and attempting to breath out against a closed glottis)
Clamp tube
Obtain purse string
Evenly and gently pull the tube out while the other RN pulls on the purse string to draw
the wound margins together, preventing re-entry of air into the pleural space
Dress with occlusive dressing

Post removal
Monitor respiratory status
Document time of removal
Order an chest x-ray approx. 30min post removal

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 COLLECTION CHAMBERS

One-way mechanism:
The simplest way to create a one-way valve is the use of an underwater seal. The distal end of
the drainage tube is placed about 2cm beneath the surface of a solution, preferably sterile water
or saline. This water seal creates a closed chest drainage system by closing off the open end of
the tubing from the atmosphere.

A slightly positive pressure in the pleural space during exhalation or coughing will force air out
of the pleural space through the tubing. Once the small amount of water in the straw is pushed
out of the way, the air will bubble out into the solution. But air can no longer be drawn back up
through the solution into the chest.

One-Bottle System:
This is the simplest closed chest drainage system. The drainage tubing is connected to a rigid
straw that extends into a single sterile plastic bottle that serves as both a collection chamber and
a waterseal. Sterile water or saline is poured into the bottle so the straw is submerged about 2cm.

An exit “vent” lets incoming pleural air form the patient escape from the chamber into the
atmosphere. Otherwise enough pressure could build up in the bottle to prevent any more pleural
air from coming in (ensure the protective plastic cap is removed)

Drawbacks of a One-Bottle System:

The bottle is used not only as the waterseal but as a drainage bottle and at times suction chamber
too. As drainage fills the bottle, more of the waterseal is submerged. More force is then needed
(by the patient) to push the solution inside the straw out of the way allowing pleural air and
liquid drainage into the bottle. Emptying the drainage bottle once it reaches 200mls or more can
solve this problem. Alternatively separate collection bottle between the drainage tubing and the
water-seal bottle can be used (see two-bottle system below).

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Two-Bottle System:
In the two-bottle system, drainage falls into the collection bottle and air flows beyond into the
separate waterseal bottle. This setup keeps the waterseal at a fixed level and allows more
accurate observation of the volume and type of drainage. As with the one-bottle system, the
water seal bottle must have an exit vent to the atmosphere that allows incoming pleural air to
escape. Bubbling from an air leak and fluctuations in the waterseal straw will occur in the same
way as they do in the one-bottle system.

Drawbacks in the Two-Bottle System:

The separate collection bottle adds dear-air space to the drainage system – a reservoir of air that
can be drawn into the pleural space. The two-bottle system (and one-bottle system) limits gravity
chest drainage. To drain air and liquid from the pleural space, pressure must be higher in the
chest the in the bottles. Placing the bottles below the chest creates the pressure difference;
additional pressure is created at the patient end of the tubing by expiration and coughing. The
drainage system must be able to handle enough airflow to match the size of the patient’s air leak.
Sometimes the pressure difference and airflow capacity of gravity drainage system aren’t enough
and suction must be added.

Three-Bottle System:
The safest way to regulate the amount of suction is to add a third, or control bottle to the
drainage system. The third bottle in the system is used to set a maximum limit on the negative
suction pressure that is imposed on the pleural space. This maximum pressure is determined by
the height of the water column in the air inlet tube. Negative pressure (from wall suction) draws
the water down the air inlet tube, and when the negative pressure exceeds the height of the water
column, air is entrained from the atmosphere. Water is added to the suction-control chamber to
achieve a water level of 20cm. The wall suction is then activated and slowly increased until
bubbles appear in the water. This bubbling indicates that atmospheric air is being entrained and
the maximum negative pressure has been achieved.

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 Dry Suction system
The Heimlich valve, created by Dr. Henry Heimlich is best suited for an uncomplicated
pneumothorax or haemothorax that requires little or no drainage collection or suction. This valve
is not used in the general intensive care areas but may be seen on patients on intra hospital
transfers due to its portability, lightweight and the ability of the valve to function in any position.
It does not need to be below the chest cavity.

The Heimlich valve is made of clear plastic and attached to connecting tubing, which in turn
attaches to the patient’s chest tube or small bore percutaneous catheter. The valve consists of
rubber flutter leaflets that are compressed at the distal end. These leaflets allow one-way flow so
that air, fluid or blood clots exiting through the valve can’t return to the pleural space.
If drainage is excessive,
Physician can withdraw air or fluid with a syringe by unscrewing the connecting tubing
form the stopcock. A bag can be attached to the valve if there is a persistent amount of
small drainage. Small holes or a .5cm tear should be made towards the top of the bag to
allow air to escape otherwise tension pneumothorax may result.
The drainage fluid can also cause the valve to stick so both nurse and the patient need to
be aware of the signs of tension pneumothorax: increasing dyspnoea, +/- pain, reduced air
entry to the affected side and a mediastinal shift / tracheal displacement to unaffected side.
Should you suspect a tension pneumothorax the valve should be changed immediately. In
an emergency or in the absence of another valve, disconnecting the valve from the ICC
will allow air to escape giving immediate relief to the patient. The tube can then be
attached to a conventional UWSD bottle system.
Dressings to the ICC site should be done as required when wet or at least Daily to observe
the site.
The valve should be changed weekly. The tube is clamped with Kocher clamps
momentarily while the valve is changed and secured as per instructions earlier in this
protocol.
The bag should be changed as frequently as required or weekly. It is important that fluid
does not cause the tear in the bag to stick together preventing air escaping.

It can also be attached to suction if required. (See pictures below)

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REFERENCES
Butcher L & Melinda, S. (1999). Critical Care Nursing. W. B> Saunders Company, Philadelphia
Marino, P. L. (1998). The ICU Book.Lippincott Williams & Wilkins, Philadelphia
O’Hanlon-Nuchols, T (1996). Commonly Asked Question about Chest Tubes. American Journal
of Nursing (AJN) May 1996. Vol.96, No5
Oh, T. E. (1997). Intensive Care Manual. Butterworth Heinemann, London.
Pettinichhi, T. A. (1998) Trouble shooting chest Tubes. Nursing98, March pp58-60
Peek, J.G (2000) Clinical review: The Pleural Cavity. BMJ Vol.320 13 May 2000
Product Information Sherwood Davis & Gecko (1999). Understanding Underwater Chest
Drainage.
Occupational Health and Safety: Universal precautions taken in the preparation, administration of drug and
disposal of equipment and sharps.
Cross Referenced: RPAH Occ. Health & Safety Manual and Infection Control Manual
NSW Infection Control Policy 98/99
Revised by: Frankie Hopkins (ACNC) January 2002
Reviewed by: Morgan Smith (Ed.Cardiothoracic)
Authorised and assisted by: Dr. Richard Totaro (Intensivist ICU) January 2002
Revision January 2004

With the introduction of Powerchart online ordering, a clinical agreement has been set up
with the Director of ICS and other Staff Specialists. Nursing Management, with the
agreement of the hospital executive, have made arrangement that allows all permanently
employed RPAH Nursing Staff to place orders for a variety of tests on their behalf. It is a
Health Insurance Commission (HIC) directive that all orders placed by nursing staff are
countersigned by the responsible MO within 14 days.

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